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STATE ID NUMBER 00000038874001 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 01 RUBBER LINED ( 1 02 ALKYD LINING C ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> (X) 07 UNLINED ( ) 08 UNKNOWN ( ) 09 OTHER: <br /> F. C 1 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING { 1 03 CATHODIC PROTECTION f ) 04 UNKNOWN ( ) 05 NONE <br /> (X1 06 TAR OR ASPHALT ( ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: ( l 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXES) [ 1 04 PRESSURE ( 1 05 SUCTION f J 06 UNKNOWN ( 1 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( 3 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (X) 04 PRESSURE [ 1 05 SUCTION ( 1 06 UNKNOWN C 1 07 NONE <br /> VII LEAK DETECTION <br /> ( 1 01 VISUAL CX) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS f i 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU APE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CUFPENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> S70PED STOP_D <br /> ( ) 01 f ) 02 ( 1 03 <br /> ( ) O1 ( ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( l 03 <br /> ( ) 01 { 1 02 ( ) 03 <br /> ( ) <br /> 01 C 1 02 ( ) 03 <br /> ( ) 01 ( ] 02 ( ) 03 <br /> 01 ( ] 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( 1 03 <br /> C 1 01 f ) 02 ( 1 03 <br /> ( 1 01 ( 1 02 ( ) 03 <br /> # CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FARM? ( 1 01 YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PEPSIN FILIN� (SIGNATURE) PHONE W/APEA CCDE <br /> ✓C�✓ o <br /> FOR LOCAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> ,� Ooc cc <br /> CONTACT PERSO P N�Ery(W�/APEA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TP.ANSACTION DATE LOCAL PERMIT I0 # <br /> ( ) QI YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />